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Updates on Coronary Artery Disease and Interventional CardiologyJoseph Yang, MDAssistant Clinical ProfessorDivision of CardiologyDepartment of MedicineSan Francisco VA Health Care SystemUniversity of California, San Francisco
Disclosures I have no relevant financial relationships with any companies related
to the content of this course.
I am an Interventional Cardiologist (more of a disclaimer, not of financial relevance)
2018-2019: A Potpourri
Thiele NEJM 2018. Stone NEJM. Mack NEJM 2019. Popma NEJM 2019.
2019-2020: Mostly Coronary Disease
The Year in Interventional CardiologyComplete Revascularization after Myocardial Infarction
Revascularization in Stable Coronary Disease
Duration of Antiplatelet Therapy with Drug Eluting Stents
CABG vs. PCI for Left Main Disease
COVID-19 and Myocardial Infarction
Complete Revascularization after Myocardial InfarctionCOMPLETE Trial
First, a quick trip back to 2013: The PRAMI Trial
Mehta NEJM 2019
Wald NEJM 2013
Levine Circulation 2016
COMPLETE Trial
Mehta NEJM 2019
First Co-Primary Endpoint: Composite of Cardiovascular Death and MI
Second Co-Primary Endpoint: Composite of Cardiovascular Death, MI, or Ischemia-Driven Revascularization
Mehta NEJM 2019
Mehta NEJM 2019
Mehta NEJM 2019
Revascularization in Stable Coronary Disease ISCHEMIA Trial
ISCHEMIA Trial
twitter.com: #ISCHEMIA
Bolden NEJM 2007
First, a look back:
COURAGE Trial
2007
Maron NEJM 2020
Primary Composite Outcome:
• Death from CV causes
• MI
• Hospitalization for unstable angina
• Heart failure
• Resuscitated cardiac arrest
Maron NEJM 2020
Maron NEJM 2020
Maron NEJM 2020
Maron NEJM 2020
Maron NEJM 2020
Spertus NEJM 2020
twitter.com: #ISCHEMIAwww.latimes.com
Duration of Antiplatelet Therapy with Drug Eluting StentsSTOPDAPT-2 TrialTWILIGHT TrialONYX ONE Trial
Watanabe JAMA 2019
Watanabe JAMA 2019
Watanabe JAMA 2019
Mehran NEJM 2019
Mehran NEJM 2019
Primary Outcome: Bleeding
Mehran NEJM 2019
Secondary Endpoint: Ischemic Events
Mehran NEJM 2019
Windecker NEJM 2020
Windecker NEJM 2020
Windecker NEJM 2020
CABG vs. PCI for Left Main Disease
EXCEL Trial: 5 year resultsPRECOMBAT Trial: 10 year results
Stone NEJM 2019
Stone NEJM 2019
PCI: higher Death from any cause
18/30 additional deaths in PCI group adjudicated as non-cardiac
Stroke and MI did not differ
PCI: more revascularization
Stone NEJM 2019
Stone NEJM 2019
Composite endpoint:
• Death
• Stroke
• MI
Early benefits of PCI diminished over time
• 0-30 days: less events after PCI
• 30 days-1 year: Similar
• 1-5 years: less events after CABG
Stone NEJM 2019
www.bbc.co.uk
Watanabe Circulation 2020
Watanabe Circulation 2020
Brophy JAMA Int Med 2020
Kinnaird. Circ Cardiovasc Interven 2020
COVID-19 and Myocardial Infarction
Mahmud Catheter Cardiovasc Interven 2020
Mahmud Catheter Cardiovasc Interven 2020
Bangalore NEJM 2020
www.nytimes.comSlide courtesy of Gregory Judson, MD
Garcia JACC 2020Slide courtesy of Gregory Judson, MD
Solomon NEJM 2020
Late Presentations
www.twitter.comSlide courtesy of Gregory Judson, MD
Take Home (No Contact Delivery) PointsSTEMI: Complete revascularization preferred over culprit-vessel
only.
Stable CAD: Can be managed medically if you exclude left main disease. PCI improves symptoms and maybe more? Longer-term outcomes hopefully still on the way.
DAPT duration: Guidelines still say 6 or 12 months. In high bleeding risk, single agent is likely safe after 1-3 months.
Left main disease: Heart Team discussion is needed. Operator volume seems to matter.
COVID-19: Public awareness of cardiovascular disease is important!
Thank you
References Bangalore, S., Sharma, A., Slotwiner, A., et al. 2020. ST-Segment Elevation in Patients with Covid-19 - A Case Series. The New England
Journal of Medicine. In press.
Boden, W.E., O’Rourke, R.A., Teo, K.K., et al. 2007. Optimal medical therapy with or without PCI for stable coronary disease. The New England Journal of Medicine 356(15), pp. 1503–1516.
Brophy, J.M. 2020. Bayesian interpretation of the EXCEL trial and other randomized clinical trials of left main coronary artery revascularization. JAMA internal medicine. In press.
Garcia, S., Albaghdadi, M.S., Meraj, P.M., et al. 2020. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. Journal of the American College of Cardiology 75(22), pp. 2871–2872.
Kinnaird, T., Gallagher, S., Anderson, R., et al. 2020. Are higher operator volumes for unprotected left main stem percutaneous coronary intervention associated with improved patient outcomes?: A survival analysis of 6724 procedures from the british cardiovascular intervention society national database. Circulation. Cardiovascular Interventions 13(6), p. e008782.
Levine, G.N., Bates, E.R., Blankenship, J.C., et al. 2016. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 133(11), pp. 1135–1147.
Mack, M.J., Leon, M.B., Thourani, V.H., et al. 2019. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. The New England Journal of Medicine 380(18), pp. 1695–1705.
Maron, D.J., Hochman, J.S., Reynolds, H.R., et al. 2020. Initial invasive or conservative strategy for stable coronary disease. The New England Journal of Medicine 382(15), pp. 1395–1407.
Mehran, R., Baber, U., Sharma, S.K., et al. 2019. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. The New England Journal of Medicine 381(21), pp. 2032–2042.
Mehta, S.R., Wood, D.A., Storey, R.F., et al. 2019. Complete Revascularization with Multivessel PCI for Myocardial Infarction. The New England Journal of Medicine 381(15), pp. 1411–1421.
References continued Park, D.-W., Ahn, J.-M., Park, H., et al. 2020. Ten-Year Outcomes After Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Left
Main Coronary Disease: Extended Follow-Up of the PRECOMBAT Trial. Circulation 141(18), pp. 1437–1446.
Popma, J.J., Deeb, G.M., Yakubov, S.J., et al. 2019. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. The New England Journal of Medicine 380(18), pp. 1706–1715.
Solomon, M.D., McNulty, E.J., Rana, J.S., et al. 2020. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. The New England Journal of Medicine. In press.
Spertus, J.A., Jones, P.G., Maron, D.J., et al. 2020. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. The New England Journal of Medicine 382(15), pp. 1408–1419.
Stone, G.W., Kappetein, A.P., Sabik, J.F., et al. 2019. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. The New England Journal of Medicine 381, pp. 1820–1830.
Stone, G.W., Lindenfeld, J., Abraham, W.T., et al. 2018. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. The New England Journal of Medicine 379(24), pp. 2307–2318.
Thiele, H., Akin, I., Sandri, M., et al. 2018. One-Year Outcomes after PCI Strategies in Cardiogenic Shock. The New England Journal of Medicine 379(18), pp. 1699–1710.
Wald, D.S., Morris, J.K., Wald, N.J., et al. 2013. Randomized trial of preventive angioplasty in myocardial infarction. The New England Journal of Medicine 369(12), pp. 1115–1123.
Watanabe, H., Domei, T., Morimoto, T., et al. 2019. Effect of 1-Month Dual Antiplatelet Therapy Followed by Clopidogrel vs 12-Month Dual Antiplatelet Therapy on Cardiovascular and Bleeding Events in Patients Receiving PCI: The STOPDAPT-2 Randomized Clinical Trial. The Journal of the American Medical Association 321(24), pp. 2414–2427.
Windecker, S., Latib, A., Kedhi, E., et al. 2020. Polymer-based or Polymer-free Stents in Patients at High Bleeding Risk. The New England Journal of Medicine 382(13), pp. 1208–1218.
